Polio Cases Research Articles

Current polio global eradication and control policy options: perspectives from modeling and prerequisites for oral poliovirus vaccine cessation

As the Global Polio Eradication Initiative progresses toward the eradication of wild polioviruses, national and global health leaders must still actively consider options for managing poliovirus risks, including risks associated with using oral poliovirus vaccine. Oral poliovirus vaccine continues to represent a highly effective tool, but its use causes noticeable, rare cases of vaccine-associated paralytic polio and with low coverage it can evolve to become circulating vaccine-derived polioviruse that causes outbreaks. National leaders face a wide range of options, but their choices depend in part on global policies. This article explores the current set of global options for poliovirus eradication or control, discusses constraints and prerequisites for their implementation and offers some insights based on dynamic modeling to inform discussions and frame future economic analyses.

Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India

The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication. PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey. A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p<0.0001) and that polio disease was severe in a child aged 1-5 years (77.7% vs. 62.2%, p<0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents' lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio. PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated.

Support for children identified with acute flaccid paralysis under the global polio eradication programme in Uttar Pradesh, India: a qualitative study

BackgroundCases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis.MethodsThe research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed.ResultsMinimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their children's disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis.ConclusionsDespite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.

Polio: Eradicated, But Can It Return?

th is World Polio Day. This communicable disease spreads through human-to-human contact, usually entering the body through the mouth due to faecally contaminated water or food, causing paralysis of essential muscles, such as those controlling swallowing, heartbeat, and respiration. Sixty years ago, the largest number of polio victims was reported in the United States. In 1952, there were 57,879 cases reported with 3,145 deaths. In a weeklong special son National Public Radio (NPR) News, McCarthy [1] reported that India has been free of polio that has afflicted it for millennia. India has 175 million children aged 5 years and younger and all of them are the target for the massive campaign that has nearly enabled India to claim a polio-free status. With this success, the world has never been closer to eradicating polio. Since World Polio Day in 2011, India is able to claim no new cases since January 11, 2011. This is historic and offers hope and a resurgence of effort to eradicate this crippling disease in the few active regions of remaining endemic countries. NPR reports that a decade ago, Nigeria perceived the war on polio to be a “Western plot to sterilize Muslim children” [2]. Conversely, the countries of India and Pakistan may find polio to be the ultimate exercise in diplomacy in that polio may knit program strategies together as they seize this historic moment for global health [1]. Since the 2011 World Polio Day, the number of new cases of polio has declined from 467 at this time last year to 171 this year. In the developing world, children are given an oral vaccine made of a live, no paralytic polio virus. The vaccination entails two drops for partial immunity, making mass vaccination campaigns achievable in poor countries [3]. The vaccine causes an infection that usually lasts a few weeks. The infection can spread to others and immunize them, too. However, but if the virus spreads too far among previously unvaccinated people, its genes will change and the virus will regain its ability to cripple and kill such as the outbreak of paralytic polio in Haiti and the Dominican Republic in 2000 and 2001, crippling 21. The World Health Organization reported more than 1,300 cases of the disease in 16 countries in 2005, with cases in Indonesia, South Asia and West Africa. Our strongest motive for writing this editorial was to take this opportunity to thank the medical professionals who worked during the polio epidemic and to recognize the efforts of the health staff of the time whose names never made it to print. The health professionals of the day not only rose to the challenge, but learned from it; their robust and optimistic response has ultimately eradicated the disease hopefully.

Isolation of different viruses from diarrhoeal and non-diarrhoeal stool samples in children at our centre at Karachi, Pakistan

This study is done for period of one year. Stool samples 229 children up to the age of six years were included for isolation of viruses. Rota-virus was excluded from this study (separate study). This study was done in collaboration of the Nagoya University Nagoya, Japan. The 26 cases of clinical polio were subjected for enteroviruses isolation 24 (92.3%) were positive. Diarrhoeal stools were 126 out of which 62 (49.2%) positive for enteroviruses. Stool samples from healthy individuals were 77 from which 17 (22.1%) were having enteroviruses. Overall out of 229 stool samples 103 (45.0%) were having enteroviruses. Different species like polio-1, polio-2, polio-3, non-polio enterovirus, adenovirus (3 and 11), ECHO (3, 6, 7, 12, 19 and 21) and cox A10 were isolated in children. It is necessary for us to look for preventive strategies against these viruses to cope with pathogenic viruses.

Trends in the Risk of U.S. Polio Outbreaks and Poliovirus Vaccine Availability for Response

The United States eliminated indigenous wild polioviruses (WPVs) in 1979 and switched to inactivated poliovirus vaccine in 2000, which quickly ended all indigenous live poliovirus transmission. Continued WPV circulation and use of oral poliovirus vaccine globally allow for the possibility of reintroduction of these viruses. We evaluated the risk of a U.S. polio outbreak and explored potential vaccine needs for outbreak response. We synthesized information available on vaccine coverage, exemptor populations, and population immunity. We used an infection transmission model to explore the potential dynamics of a U.S. polio outbreak and potential vaccine needs for outbreak response, and assessed the impacts of heterogeneity in population immunity for two different subpopulations with potentially low coverage. Although the risk of poliovirus introduction remains real, widespread transmission of polioviruses appears unlikely in the U.S., given high routine coverage. However, clusters of un- or underimmunized children might create pockets of susceptibility that could potentially lead to one or more paralytic polio cases. We found that the shift toward combination vaccine utilization, with limited age indications for use, and other current trends (e.g., decreasing proportion of the population with immunity induced by live polioviruses and aging of vaccine exemptor populations) might increase the vulnerability to poliovirus reintroduction at the same time that the ability to respond may decrease. The U.S. poliovirus vaccine stockpile remains an important resource that may potentially be needed in the future to respond to an outbreak if a live poliovirus gets imported into a subpopulation with low vaccination coverage.

Compassion and Compensation for Polio Cases

Aim: To find if some children had developed paralytic poliomyelitis despite participating in the national polio eradication program. Methods: Data of National Polio Surveillance Project regarding polio eradication program in India was analysed. Results: Many children have developed paralytic poliomyelitis despite taking many doses of OPV because of vaccine failure and many children have developed VAPP after taking OPV and some children have developed VAPP because of secondary spread of mutant polio viruses. Conclusion: The children who have developed polio during polio eradication program are considered as ‘price to be paid’ for larger interest of the society. Though the harm occurred to these children was not intentional but, nevertheless it was foreseeable. Thus, adequate compensation should be paid to such children.

ポリオウイルスワクチン

To avoid the risk of vaccine-associated paralytic poliomyelitis (VAPP) and polio outbreaks due to circulating vaccine-derived polioviruses, an inactivated poliovirus vaccine (IPV) was introduced for routine immunization in a number of countries with a low risk of polio outbreaks. Currently, production and marketing of a standalone conventional IPV and two diphtheria-pertussis-tetanus-IPV (Sabin-derived IPV; sIPV) products have been submitted, and it is expected that the IPV products will be introduced in Japan in the autumn of 2012. At the same time, a decline in the OPV immunization rate became apparent in Japan due to serious public concerns about a remaining risk of VAPP and introduction of IPV in the near future. Therefore, the recent development of polio immunity gaps should be carefully monitored, and surveillance of suspected polio cases and laboratory diagnosis of polioviruses have to be intensified for the transition period from OPV to IPV in Japan. The development of sIPV is one of the most realistic options to introduce affordable IPV to developing countries. In this regard, further clinical studies on its efficacy, safety, and interchangeability of sIPV will be needed after the introduction of the sIPV products, which will be licensed in Japan for the first time in the world.

Role of catch-up campaigns in improving immunization services in a developing country

Background: Bellary district of India had highest number of Polio cases in the world during the year 2003. This is mainly because of low level of routine immunization coverage. Successful implementation of supplementary immunization activities interrupted Polio transmission in 2003. It is important to sustain the gains made in polio immunization as well as make attempts to improve the immunization coverage against other vaccine preventable diseases. We wanted to look at the immunization coverage rates before and after the catch up campaigns to strengthen routine immunization services in this high-risk district. Aims: Our objective was to evaluate the impact of catch up campaign through estimation of immunization coverage after conclusion of catch-up campaigns in the district of Bellary. Settings and Design: The evaluation data is from a cross sectional study done in Bellary district, India by following multi stage and systematic random sampling. Materials and Methods: The study was done in three stages; In stage one, the district specific DLHS data was analyzed. In stage two; systemic issues were identified by going through immunization registers, records and identified key reasons for low vaccination coverage. In stage three, immediately after catch up immunization sessions, the coverage rates were captured using simple random sampling, and compared with DLHS data. Statistical Analysis: Data analysis was performed using SPSS Statistics 17.0 (Rel. 11.0.1 2001-SPSS Inc), R 2.11, Microsoft Excel (MS office, Version 2007, Microsoft Corporation, USA). Results: The results demonstrate that the coverage for all antigens improved due to the conduct of catch-up campaigns. Conclusions: This study compares estimates of the age-specific population immunization coverage against BCG, OPV, DPT, TT, and Measles before and after the catch up campaigns. Catch-up sessions help to address systemic issues related to routine immunization, and sustain high immunization coverage in developing countries like India.

The global polio eradication initiative: Lessons learned and prospects for success

Following the rapid progress towards interrupting indigenous wild poliovirus transmission in the Americas in the early 1980s, the Global Polio Eradication Initiative (GPEI) was launched with a resolution of the World Health Assembly (WHA) in 1988. The GPEI built on many lessons learned from smallpox eradication, including the large-scale deployment of technical assistance, implementing agendas of innovation and research and the use of professionally planned and guided advocacy. By the year 2000, the incidence of polio globally had decreased by 99% compared with the estimated >350,000 cases reported from 125 endemic countries in 1988. By 2002, three WHO Regions (the Americas, Western Pacific and European Regions) had been certified polio-free. By 2005, transmission of indigenous wild poliovirus (WPV) had been interrupted in all but 4 'endemic' countries: India, Nigeria, Pakistan and Afghanistan, where eradication efforts effectively stalled. WPV exported from northern Nigeria and northern India subsequently caused >50 outbreaks and paralysed >1500 children in previously polio-free countries across Asia and Africa. In each of the four remaining polio-endemic countries different challenges, or a combination of factors, prevented to build up sufficient levels of population immunity to stop transmission. Consequently, specific strategies were increasingly tailored to each setting. A new 2010-2012 GPEI Strategic Plan was developed which brought together several approaches to overcome the remaining hurdles to eradication, including the large-scale use of bivalent oral poliovaccine (bOPV) in supplementary immunization activities (SIAs). By the end of 2010, the impact of the new GPEI Strategic Plan 2010-2012 was apparent. Compared to 2009, the number of new polio cases in 2010 fell by 95% in both northern Nigeria and northern India, the world's largest remaining reservoirs of indigenous WPVs. By mid-2011, India had not reported a polio case for more than 5 months, and in Nigeria, endemic transmission appeared to be restricted to the north-east and north-west corners of the country. While polio cases due to WPV type 3 were still being detected in west and central Africa, the overall level of WPV3 transmission globally was at an all-time low. Uncontrolled WPV transmission appeared to be restricted to Chad and Pakistan, which increasingly represented the greatest risks to the GPEI. Although insufficient financing continued to be a major concern, political support for completing polio eradication in polio-infected countries was stronger than ever by mid-2011. While continued transmission in some areas, particularly in Pakistan and Chad, still had to be controlled as a matter of urgency, there were real opportunities to achieve new landmarks in polio eradication, especially in the key WPV reservoirs of India and Nigeria, setting the stage for polio to soon follow smallpox into the history books.

Smallpox and its eradication in the Democratic Republic of Congo: Lessons learned

Smallpox eradication is considered to be one of the most remarkable accomplishments of the 20th century. Lessons learned from the campaign during the 1960s and 1970s in the Democratic Republic of Congo (DRC) can provide important information for the development of other eradication programs including polio. The DRC is the third largest country in Africa; the population suffers from extreme poverty, deteriorating infrastructure and health systems, and long periods of civil strife. Despite these challenges, DRC's smallpox eradication campaign was successful, eradicating smallpox only 41 months after initiation. DRC had been polio free since 2001; however, in 2006, imported cases were identified in the country. Polio transmission has since been re-established and DRC now has the second greatest number of reported polio cases in the world. Challenges which existed during the smallpox campaign in DRC are still present today; additionally, the polio vaccine itself poses unique challenges which include requiring multiple doses to confer immunity. In the fight against polio in DRC, it will be important to draw from the smallpox eradication experience. A number of important themes emerged during the campaign that could be beneficial to eradicating polio and future eradication programs that may follow. During the smallpox campaign, a standard vaccination program was implemented, surveillance was intensified, and there were strong collaborative programs with community involvement. These successful elements of the smallpox campaign should be adapted and applied in DRC in polio eradication programs.

WHO's Initiatives to Control Vaccine Preventable Diseases (VPD) and Labnet for Targeted VPDs in the Western Pacific Region

WHO's Initiatives to Control Vaccine Preventable Diseases (VPD) and Labnet for Targeted VPDs in the Western Pacific Region

The Role of the Pediatrician in Preventing Congenital Malformations

The Role of the Pediatrician in Preventing Congenital Malformations

P2-347 10 years of Polio/AFP surveillance in Lebanon: 2000–2009

BackgroundEver since the 1988 poliomyelitis eradication global initiative, cases have been drastically decreasing; however, four countries remain polio reservoir sources for virus exportation. In Lebanon, the last two indigenous cases...

P2-425 Eradicability of poliomyelitis in India, new evidence from recent trends

BackgroundIn May 1988, the World Health Assembly committed the member nations of the WHO to achieving the goal of global eradication of poliomyelitis. In 2008, only four countries in the...

The Polio Endgame

Infection with poliovirus can have devastating consequences, including paralysis and death. In 1988, a year when an estimated 350,000 or more children were paralyzed by polio, the World Health Assembly initiated a global effort to eradicate the infection once and for all. It was an audacious undertaking, given that the virus circulates largely undetected, requires laborious cell-culture techniques to confirm infection, and is tackled with vaccines that provide imperfect protection in the gut. Initially, the number of polio cases and countries with infections fell rapidly, particularly as financing and political support increased in the mid-1990s. The last case of paralytic . . .

Underserved and overdosed? Muslims and the Pulse Polio Initiative in rural north India

During the 2000s, confirmed polio cases in India have been increasingly localised in Uttar Pradesh (UP) and Bihar, especially amongst Muslim children. Muslims have also been at the sharp end of the Pulse Polio Initiative (PPI) and the associated ‘Underserved Strategy’ designed to counter civilian resistance to the programme. Our critique of the PPI draws on long-term research in rural UP and focuses on the programme's socio-political implications. We discuss popular rumours about polio vaccine and official responses to resistance. Taking a longer term view of top-down single-issue public health programmes, we argue that Muslims in western UP, as a marginalised minority, have good reason to be suspicious of the PPI. Moreover, the PPI arguably reflects the agendas of global funders, not the priorities of local communities. Villagers – Hindu and Muslim alike – have repeatedly criticised government health services for failing to deal with the health issues that worry them most. Their concerns echo other critiques of the PPI, particularly the diversion of resources from other health-related activities that could address the social determinants of health and health inequalities.

Particle Agglutination Method for Poliovirus Identification

In the Global Polio Eradication Initiative, laboratory diagnosis plays a critical role by isolating and identifying PV from the stool samples of acute flaccid paralysis (AFP) cases. In the World Health Organization (WHO) Global Polio Laboratory Network, PV isolation and identification are currently being performed by using cell culture system and real-time RT-PCR, respectively. In the post-eradication era of PV, simple and rapid identification procedures would be helpful for rapid confirmation of polio cases at the national laboratories. In the present study, we will show the procedure of novel PA assay developed for PV identification. This PA assay utilizes interaction of PV receptor (PVR) molecule and virion that is specific and uniform affinity to all the serotypes of PV. The procedure is simple (one step procedure in reaction plates) and rapid (results can be obtained within 2 h of reaction), and the result is visually observed (observation of agglutination of gelatin particles).

The 1954 Salk poliomyelitis vaccine field trial

On April 12, 1955, Thomas Francis, Jr., Professor of Epidemiology at the University of Michigan, held a press conference in Ann Arbor to announce the results of a ‘field trial’ of an experimental poliomyelitis vaccine. ‘Some of the best educated persons in American journalism’ elbowed each other aside to get their hands on a copy of the press release. The journalists’ ardor was not surprising: more Americans knew about the vaccine trial ‘than knew the full name of the President of the United States’ [1]. The ‘biggest public health experiment ever’ had enrolled 1,022,684 school children in 44 states. 300,000 school teachers, ‘classroom mothers’ and ‘clubwomen,’ nurses, physical therapists, doctors, and public health officials had volunteered to organize the immunizations and track polio cases [2,3]. Around the country, vaccine supplies were stockpiled, as families, physicians, and government officials waited to hear whether the new vaccine had worked. Francis’ announcement that the vaccine was ‘80 to 90 per cent effective against paralytic poliomyelitis’ did not satisfy Jonas Salk, the vaccine’s inventor, who promised future results of ‘100 per cent’ effectiveness [1,4]. No medical study, before or since, approaches the 1954 Salk vaccine field trial in size, complexity, or the extent of public involvement. The trial was initiated not by the federal government but by a private organization, the National Foundation for Infantile Paralysis (NFIP), which raised its money from millions of small donations. Ordinary citizens paid for the study, recruited the children who took the vaccine and the volunteers who helped administer it. It is a small wonder that trialists and vaccine researchers look back admiringly, even longingly, at the study [5–8]. Yet, the most remarkable fact about the 1954 field trial may not be the massive organizational effort involved, or the rigorous methodological design ultimately imposed. Given repeated controversies about the vaccine’s safety and the field trial’s design, it is remarkable that the trial was ever begun, much less successfully completed. The sciences of vaccine testing and of clinical trials are complex. Add parents, physicians, school, and health officials from 3100þ communities and the process grows even messier, little resembling the orderly procedure the textbooks prescribe. In Pittsburgh, Jonas Salk continued modifying the test vaccine until a few months before the study was launched. The field trial itself was shaped by decisions taken not only in New York at the NFIP’s headquarters, or in Francis’ Ann Arbor, but also in places like Montgomery, Alabama, where local health and school officials decided to go ahead with the trial, and Arlington, Virginia, where the community decided against participation. In this article I will try to capture the difficulties trial organizers faced, the contingencies they encountered along the way and the actions taken to overcome these obstacles.

Working ‘off the record’: polio eradication and state immunity in Chad

The reappearance of polio in Chad generates anxieties about governance as well as public health. Since Chad was declared polio-free in 2003, at least 180 cases of paralytic polio have been linked to importations of wild poliovirus from Nigeria. In efforts to eradicate polio through house-to-house vaccination campaigns, international agencies have aggressively implicated political leaders, placing those authorities in a bind. On the one hand, governments are required to demonstrate compliance in the form of universal vaccination. On the other hand, the legitimacy of political leaders and of local authorities in particular depends upon their ability to show compassion for their populations and to be responsive to individual circumstances and concerns about the drops. This article looks at how the obligation of the African state to adopt global public health policy as its own becomes problematic when the goals and protocols of international agencies rely on the assumption that the state controls its population. Under pressure to render account to international agencies, state officials deploy high-level politicians to enforce vaccination mandates at critical moments, create administrative forms to record campaign progress that conceal difficulties in vaccinating children, and use statistics to portray the campaigns as success stories. Local authorities, who feel the bind most acutely, grant exceptions to the mandate of universal vaccination to certain subjects and work with local vaccinators and supervisors to keep cases of unvaccinated children ‘off the record’. These efforts allow the vaccination campaigns to be carried out without incident even as they work against the goal of polio eradication.